Forms

Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9)
Medical providers use this form to supply information to managed care organizations (MCOs) or self-insuring employers and to request authorization for additional treatment. Information includes: the current diagnosis; additional conditions felt to be related to the industrial accident/exposure; causal relationship of conditions to the accident/exposure; pre-existing conditions, disability and treatment plan. If a physician requests additional treatment, he/she must indicate the specific type, frequency and duration of the treatment.

Physician's Report of Work Ability (MEDCO-14) Providers of record use this form to certify an injured worker is temporarily and totally disabled due to a work injury or to identify work abilities when worker capabilities are restricted due to the work injury.